Upper extremity functional index

We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your upper limb problem for which you are currently seeking attention. Please provide an answer for each activity.

Today, do you or would you have any difficulty at all with: (select one number on each line)

Name *

Name

First Name

Last Name

Phone *

Phone

(###)

###

####

Activities

A. Any of your usual work, house work or school activities. *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

B. Your usual hobbies, recreational or sporting activities. *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

C. Lifting a bag of groceries to waist level *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

D. Lifting a bag of groceries above your head *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

E. Grooming your hair *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

F. Pushing up on your hands (e.g. from bathtub or chair) *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

G. Preparing food (e.g. peeling, cutting) *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

H. Driving *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

I. Vacuuming, sweeping, or raking *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

J. Dressing *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

K. Doing up buttons *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

L. Using tools or appliances *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

M. Opening doors *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

N. Cleaning *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

O. Tying or lacing shoes *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

P. Sleeping *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

Q. Laundering clothes (e.g. washing, ironing, folding) *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No DifficultyOption Two

R. Opening a jar *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

S. Throwing a ball *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

T. Carrying a small suitcase with your affected limb *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

Thank you!

We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your upper limb problem for which you are currently seeking attention. Please provide an answer for each activity.

Today, do you or would you have any difficulty at all with: (Circle one number on each line)